• Are any of the following observed?   

• Are bed rails (full, half, quarter, or grab bars) in use? If so, are they properly installed (e.g., are the bed rails loose or broken) and do they fit the bed properly so the resident can’t get caught between the bed rails and mattress? 

• Is the mattress of proper size and fit for the bed to prevent the resident from becoming entrapped? 

• Is the resident’s restraint/device properly applied?  If not, does the restraint/device have the risk or likelihood of causing serious injury, harm or death?  

• Are electric cords, extension cords, or outlets in disrepair/used in unsafe manner? 

• Is safety equipment in bedroom/bathroom inadequate (grab bars, slip surface)? 

• Are there accessible chemicals/other hazards in bedroom/bathroom? 

• Is there unsafe hot water in the room?  

• Is there exposure to unsafe heating unit surfaces? 

• Is ambulation, transfer, or therapy equipment in unsafe condition? 

• Are locks disabled, fire doors propped open, irregular walking surfaces, handrails in good repair, inadequate lighting? 

• Are residents adequately supervised? 

• On a secured unit, is there sufficient staff to supervise the residents? 

• Are there any other environmental hazards or risks observed? 

Note: Each surveyor should check water temperature with their hand held under the hot water in two resident rooms (on opposite sides of the hall) per unit. Use a thermometer if there is concern that water is too hot and could potentially scald or harm residents. Target resident rooms closest to the hot water tanks/kitchen areas and resident rooms belonging to residents with dementia who may use sinks/bathtubs/showers independently.